Reducing health inequalities: What do we really know about successful strategies?

1. Reducing health inequalities: What do we really know about successful strategies? Martin McKee London School of Hygiene and Tropical Medicine and European Observatory on Health Systems and Policies

2. Our starting pointCommission on Social Determinants of Health Closing the gap in a generation Improve Daily Living Conditions Tackle the Inequitable Distribution of Power, Money, and Resources Measure and Understand the Problem Assess the Impact of Action

3. Beyond social inequalities People are differentiated in many ways that can lead to inequalities in health Education Ethnicity Religion Language Disability Liberty • Gender • Age • Occupation • Income • Wealth • Social class • Rurality Which inequalities are we trying to reduce?

4. … and these frequently coincide ... damp housing leading to increased amounts of respiratory infection; household overcrowding facilitating the spread of infection; inadequate diet associated with low incomes ... failure to perceive the seriousness of childhood illnesses by poorly educated and informed parents; stresses leading to child abuse; a generally poor environment increasing the risks of child accidents; together with the everyday strain of coping with a demanding young family in inadequate circumstances in areas suffering from multiple deprivation. (Robinson & Pinch, 1987)

5. What might work will depend on what the problem is Source: Dahlgren & Whitehead

6. <= 15 <= 12 <= 10 <= 8 <= 6 <= 4 <= 2 Men die before women, but the gap is wider in some places than in others - Male-female gap in life expectancy at birth

7. … yet this is not inevitable • No gender gap found in survival beyond age 40 in (non-smoking, non-drinking) Polish Seventh Day Adventists (Jedrychowski, Scand J Soc Med 1985) • > 50% of gender gap in life expectancy at age 15 in Finland attributable to smoking and alcohol (Martelin et al, Eur J Publ Health, 2004) For this inequality, lifestyle related factors play a major role Unfortunately, women are closing the gap, by behaving more like men

8. White Americans live longer than African Americans Life expectancy at birth

9. Deaths avoidable by timely and effective care in the United States Nolte & McKee, unpublished

10. For this inequality, access to health care matters • The obvious solution? • Universal health care (if we poor Europeans can do it, why not the world’s remaining superpower?) • If that is too difficult…. • Interpreter services, outreach workers, culturally sensitive policies, recruitment and retention of minority health workers etc. (Comonwealth Fund, AHRQ. AAACP and many others)

11. Although for some inequalities, we still don’t know (or can’t agree) what the problem is • Health outcomes are considerably better among Swedish than Finnish speakers living in Finland • “Swedish-speakers possess more structural and cognitive social capital compared to Finnish-speakers. Social capital explains to some extent health differences between the language groups.” Nyqvist et al., 2008 • “Finnish-speaking men and women reported more frequent drunkenness, suffered more frequent hangovers, and had alcohol-induced pass-outs significantly more often than men and women in the Swedish-speaking population. “It seems unlikely that the effect of social capital on the health differences between the two populations would be mediated through drinking patterns.” Paljärvi et al., 2009 • Switzerland • Deaths from circulatory disease were more common in German Switzerland, while causes related to alcohol consumption were more prevalent in French Switzerland. Faeh et al., 2009

12. Making a difference • Public health researchers have been remarkably good at measuring and understanding inequalities in health • We have been much less successful in discovering what to do about them “the philosophers have only interpreted the world, the point is to change it” Karl Marx

14. … yet we all do know what is the right thing to do(and we don’t need research) • Give very poor people money/ food/ clean water/ shelter/ protection from violence • Give everyone adequately remunerated, satisfying and rewarding jobs • Build them safe, healthy environments • Stop other people (warlords, tobacco and alcohol company executives) from killing them

15. … and vote!Gini coefficient (income after housing costs) in UK labour conservative

16. The end .... Or is it Maybe the question is how to improve the health of the most disadvantaged?

17. Some good news • The emphasis of research is gradually shifting from identification, to diagnosis, to prescription • Different ‘entry points’ for intervention and policy are being identified • Growing experience in developing, implementing and evaluating interventions and policies

18. The bad news • Pathways from disadvantage to ill-health often highly complex • Confounders lurk everywhere • Variable time lags everywhere • Interventions difficult to implement and beset with unintended consequences • Reluctance by policy makers to subject their beliefs to evaluation • Yet “natural” experiments can be very misleading … all else being equal … except that it rarely is

19. …and context is all The Netherlands England Czech Republic

20. First steps • Decide who are the disadvantaged groups • Discover how they are disadvantaged • Discover how this is impacting on health • Identify where it may be possible to intervene • Find the evidence

21. Who are the disadvantaged?the invisible people

22. Where is the evidence?

23. A useful framework? • strengthening individuals • strengthening communities • improving access to essential facilities and services • encouraging macroeconomic and cultural change (Dahlgren & Whitehead)

24. Strengthening individuals • Focus on big issues and help people to make healthy choices • Legislation – such as ban on smoking in public places • Fiscal – such as taxation on unhealthy products • Empowerment • Smoking is a good place to start as studies consistently show it explains a substantial proportion of socio-economic inequalities (although there is the secondary question of why poor people smoke)

25. Smoking: evidence on where • Workplace • Individually targeted interventions (physician advice, counselling, NRT) work, self-help doesn’t • School • No convincing evidence of effectiveness of social influences and social competence interventions • Pregnancy • Smoking cessation programmes work (6 fewer women per 100 smoke) • Patients in hospital • Intensive interventions over > 1 month work Source: various Cochrane reviews

26. Smoking advice: Evidence on who does it? • Nurses • Increased odds ratio for quitting (1.47) • Less effective when in context of screening intervention • Physicians • Increased odds ratio for quitting (1.74) • Intensive intervention marginally more effective • Partner support • No convincing evidence of effect Source: various Cochrane reviews

27. Individual or collective? California China

28. Strengthening communities • Economic growth • More jobs • More pleasant environment • Reduced crime • Better education

29. More jobs • Welfare to work programmes widely used in US but gradually spreading to Europe • All (46) RCTs so far from USA • Small but consistent effect on earnings ($11,021 vs $8,843) • For every 33 participants, an extra one (compared with controls) will be in long term employment) (Smedslund et al, 2006) In all countries studied so far, those in employment are in better health than those who are not, even when the unemployed get 100% salary replacement

30. Health and the environment

31. Health and the environment • Perceived safety and attractiveness of environment associated with physical activity • Objective measures of walkability associated with physical activity • Density of fast food outlets associated with obesity

32. Changing your environment: The Moving to Opportunity project • Between 1994-97, 4248 families in Baltimore, Boston, Chicago, Los Angeles and New York were randomly assigned to: • Housing voucher that could be used to move to a low poverty (<10%) neighborhood along with mobility counseling; • Housing voucher with no geographic restrictions; • Control group (no new assistance, but continued to be eligible for public housing). Kling et al, various dates

33. Moving to Opportunity: results in 2002 • Girls moving to low poverty area: • improved educational attainment 83 v 77% graduated or still in school) • Better mental health (Odds of generalized anxiety disorder 70% less) • Less crime (33% lower lifetime arrests) • Boys moving to low poverty area: • 13% more likely to have been arrested • Tripling of alcohol use, with larger increases in smoking and marijuana use • Significant increase in non-sports injuries

34. Reducing crime • Vast majority of published studies show non-custodial sentences reduce reoffending, but meta-analysis of 4 RCTs and 1 natural experiment show no difference (Killias et al., 2006) • Close circuit TV cameras are effective, but mainly against vehicle crime when in car parks • Improved street lighting is very effective (Farringdon & Welsh, 2008) • Enhanced policing of crime hot-spots is effective (Braga, 2007) • Mentoring of juvenile offenders is moderately effective – more so for dealing with delinquency and aggression but less so in tackling drug use and low achievement. Better where emotional support central. Swedish people aged 35-64 living in violent neighbourhoods had higher incidence of coronary heart disease, after adjusting for other factors (Odds ratios: Female 1.75 (CI 1.37–2.22) / Male 1.39 (CI 1.19–1.63). Sundquist et al, 2006

35. Better education

36. Improving education • After school programmes show no demonstrable impact on children’s educational attainment (Zeif et al., 2006) • Parental involvement interventions achieve significant improvements in reading and maths • Education and Training (for parents) • Rewards and Incentives (for children based on in-school performance) (Nye et al, 2006)

37. Head Start • Pre-school programme for children from poor families • Launched in 1960s under LBJ • Evidence of early benefits – numeracy and literacy • But also evidence of Head Start Fadeout

38. In the long term…. • Whites • Participation associated with a significantly increased probability of completing high school, attending college, elevated earnings in early twenties. • African Americans • Participation associated with significant reduction in being charged or convicted of a crime • Greater probability than siblings to complete high school. • Some evidence of positive spillovers from older children who participate to their younger siblings, particularly with regard to criminal behaviour.

39. Improving access to essential services • More difficult to study than you might think • Access involves: • Relationships over time – not one-off • Decisions not only made by individuals but also families and friends • Proximity does not equal access • Evidence is contextually bounded (Balabanova, McKee et al, 2006)

40. Increasing uptake of services (and better services) • Cervical screening • Invitation letters work, educational materials have limited effect • Mass media • … campaigns can be effective in increasing uptake of essential services • UK Quality and Outcomes Framework in general practice has reduced inequalities Source: various Cochrane reviews Source: Roland et al

41. Encouraging macroeconomic and cultural change 54% 49% 50% 24% 44% 71% 72% 62% 63% 59% 71% Source: Fritzell & Ritakallio 2004 using Luxembourg Income Study data, CSDH Nordic Network

42. Welfare regimes matter:Odds of poor/fair health in unemployed compared to employed by welfare regime (for example, in Anglo-Saxon welfare states, unemployed almost 3 times more likely to be in poor/fair health than employed) Bambra et al., 2009

43. Possible explanations • Anglo-Saxon systems are simply mean • Low wage replacement levels • Means testing • Bismarckian systems emphasise role of male breadwinner • Scandinavian systems provide lower benefits for females who accumulated fewer entitlements through part-time working • Eastern systems have more informal support systems Bambra et al., 2009

44. Some policy innovations • Policy steering mechanisms • Labour market and working conditions • Health-related behaviour change • Territorial approaches. (Source: Mackenbach & Bakker)

45. Policy steering mechanisms • Quantitative targets • Reduction of inequalities in 11 intermediate outcomes (poverty, smoking, working conditions, ….) – Netherlands • Health inequalities impact assessment • Qualitative assessment of impact on health inequalities of EC agricultural policy – Sweden Very little evidence of effectiveness – but equally, no evidence they are ineffective

46. Labour market and working conditions • Universal approaches • Strong employment protection and active labour market policies for chronically ill citizens – Sweden • Occupational health services offering annual check-ups and preventive interventions to all employees – France • Targeted approaches • Job rotation among dustmen – Netherlands Some evidence of effectiveness – active labour market policies may protect in face of recession

47. Health-related behaviours • Universal approaches • Serve low-fat food products through mass catering in schools and workplaces – Finland • Targeted approaches • Multi-method intervention to reduce smoking among low income women – Britain Considerable evidence of effectiveness, but context important

48. Territorial approaches • Comprehensive health strategies for deprived areas • Health Action Zones – England • Community regeneration Systematic review of 19 studies “There is little evidence of the impact of national urban regeneration investment on socioeconomic or health outcomes. Where impacts have been assessed, these are often small and positive but adverse impacts have also occurred.” Thompson et al, 2006

49. Tough on ill health, tough on the causes of ill health… • Are we willing to tackle the immediate causes of ill-health (tobacco, alcohol, poor nutrition)? …or do we think this is just a sticking plaster …. • Or instead do we want to change society fundamentally?

50. … and don’t assume we are all agreed … on Hurricane Katrina “Shame on anyone that makes this tragedy political, socio-economic or racial. … in the land of opportunity and personal responsibility the individual is ultimately accountable.” Robert Buckley, Decatur, USA BBC web site Medicine is a social science and politics is nothing but medicine writ large ” Rudolf Virchow